Pericarditis

Background

Causes:

- idiopathic

- infectious, including AIDS related

- malignancy: heme, lung, breast

- uremia

- post radiation

- connective tissue dz

- drugs: procainamide, hydralaine, methyldopa, anticoagulants

- cardiac injury (can see up to weeks later): post MI, trauma, aortic dissection

Diagnosis

- usually sharp pleuritic chest pain, but can be anything

- radiates to chest, back, trapezius ridge

- diminish with sitting up/lean forward

- SOB, esp if concommitant pleural effusion

- hypotension/extremis if tamponade

Workup

EKG is virtually diagnostic

- less reliable in post MI patients and others with baseline EKG abnormalities

- if pt. has early repol.confounding interpretation, check (ST elev)/(T height) in V6; if >0.25 likely pericarditis

EKG progression:

1) global concave up ST elev, +/- PR depression

2) ST to baseline, big T's, PR dep

3) T wave flatten then inversion

4) return to baseline EKG

CXR, WBC, ESR, CK-MB, TN all nonspecific.

Echo will show NL wall motion

 - also useful to monitor progress

Friction rub

Differential Diagnosis

MI is the big confounder

MI Pericarditis no fever fever

pain varries w/motion

focal ST chgs diffuse ST elev reciprocal chgs no reciprocal chgs Q waves no Q wave +/- pulm edema clear lungs wall motion abn nl wall motion

also on DDx:

CHF, PE, PTX, aortic dissection, pneumomediastinum, pleuritis

Treatment

- Mostly supportive

- NSAIDS for viral/idiopathic

- Recurrent - colchicine

- Uremic - dialysis

-"buy time" with fluid boluses

- Tamponade --> pericardiocentesis

    (See Procedures: Pericardiocentesis)

Disposition

- Most need admission, but if young and healthy can echo, and D/C with close f/u

Risk Stratification

HIGH RISK (admit)

1) Subacute sx (several dys-wks)

2) Fever >100.4

3) Evidence of tamponade

4) Large effusion (>20mm)

5) Immunosupressed

6) On anticoagulant

7) Acute trauma

8) Failure to respond to NSAID Rx (>7dy)

Complications

Tamponade/Effusion-see Pericardial Effusion and Tamponade

Recurrence===

-usually weeks to months after initial episode

-management is same

Contrictive Pericarditis==

-restrictive picture with pericardial calcific on CXR and thicken on ECHO

- Rx window

Source

Adapted from Pani, Donaldson, and UpToDate